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Mycotic Aneurysm


Mycotic Aneurysm

Article Author:
Hafsa Majeed
Article Editor:
Faran Ahmad
Updated:
7/15/2020 10:41:53 PM
For CME on this topic:
Mycotic Aneurysm CME
PubMed Link:
Mycotic Aneurysm

Introduction

A mycotic aneurysm is dilation of an arterial wall due to infection. The term "mycotic" was coined by Willaim Osler in his Gulstonian lectures, where he described a man with multiple aortic mycotic aneurysms in a patient with valve vegetations, which resembled the appearance of a fleshy fungus.[1] It does not refer to fungal etiology, as the majority of infected aneurysms are caused by bacterial pathogens. Therefore the correct term of these aneurysms can be an infected aneurysm. Infectious aortitis refers to vessel infection without aneurysmal dilation. An infected aneurysm develops in the setting of an antecedent systemic infections with bacteremia or through the direct local invasion of the vessel wall (e.g., IV drug users) in the pre-existing aneurysm or atheromatous plaques.[2] 

The risks are higher in immune-compromised host i.e., HIV, diabetes, high dose glucocorticoids, or malignancy/chemotherapy.[3] Commonly involved vessels are femoral, followed by aorta, then intracranial visceral (e.g., superior mesenteric, splenic) arteries.[4][5] Natural history is characterized by expansion, leading to pseudoaneurysm formation (contained rupture), rupture, hemorrhage, sepsis, and subsequent multiorgan failure. Mycotic aneurysms are one of the most challenging clinical problems for the vascular surgeon due to the associated peri-operative mortality.[6]

Etiology

Factors Implicated in the Pathogenesis of Mycotic Aneurysms 

  • Bacteremia: Pre-existing vessel injury predisposes to infection of intima due to bacterial seeding. This is common in older age due to pre-existing atherosclerosis or aneurysm, which predisposes to infection during severe infection or sepsis. Aorta is the most common location due to the high prevalence of atherosclerosis and aneurysm. 
  • Local Injury and Bacterial Inoculation: Vascular injury resulting from IV drug abuse, trauma, or iatrogenic causes like percutaneous intervention, can inoculate bacteria into the vascular wall. This is commonly seen in arteries of extremities like femoral, common iliac, or subclavian and carotid arteries.
  • Local Spread: Extention of infection to local arteries can result in subsequent arterial inflammation, seen in vertebral osteomyelitis and intra-abdominal pathologies like appendicitis, pyelonephritis, and cholecystitis.
  • Septic Emboli: Infective endocarditis is associated with emboli in vasa vasorum resulting in inflammation of vascular wall and subsequent mycotic aneurysm. These emboli tend to be multifocal and involve the intracranial arteries at branch points.

Epidemiology

Incidence is rare, and 0.7 to 3% of aortic aneurysms are infectious in origin.[7][8] These are more common in men than women due to the higher incidence of atherosclerosis, with a higher incidence in patients who smoke or have diabetes mellitus. The median age of patients is around 65 years. The most commonly involved arteries are the femoral arteries, aorta, splanchnic (superior mesenteric, hepatic and splenic arteries), and cerebral arteries. The common pathogens in Western countries are Staph. aureus (28%), Salmonella spp (15%), and Pseudomonas aeruginosa (10%), while most Asian countries consistently reported Salmonella as the most common pathogen.[6] 

There have been case reports of coronary mycotic aneurysms post-stent placements and renal artery mycotic aneurysms in renal transplant recipients.[9] Intracranial mycotic aneurysm complicates nearly 2-10% of infective endocarditis (IE), more so with left-sided IE.

Pathophysiology

The combination of arterial injury and bacterial seeding results in infection of the intima. Once microorganisms infect the vessel wall, it rapidly degrades the deeper layers resulting in the formation of an aneurysm.[10] Bacterial infection stimulates the release of pro-inflammatory cytokines, which attracts neutrophils. These act synergistically to activate matric metalloproteinases leading to focal breakdown to the vessel wall. Some studies suggest higher MMP activity correlated with the risk of rupture; hence these can provide a prognostic indicator for risk of rupture in patients with aneurysms.[11]

Microbiology

Cultures are positive in 50-85% of the cases.[7][3] The most common pathogens are Staphylococcus aureus (28 to 71%)[4][12] and Salmonella (15%).[6] Other microbes that have been implicated are Treponema pallidum, Mycobacterium spp., Pseudomonas aerugenosa, Listeria, Klebsiella, E.coli, Clostridium, Campylobacter, H.influenzae, Yersinia, Acinetobacter, Brucella, etc.[13][14][15][16][17][18][19][20][21][22][23] Fungal organisms are seen rarely but seen in immune-suppressed states like diabetes, systemic chemotherapy or HIV infection, or following disseminate fungal infection.[24]

Histopathology

Histology from intraoperative tissue samples reveals transmural inflammation, with variable degrees of abscesses, necrosis, and thrombosis.[25] Tissue samples stain positive for bacteria in the majority of the cases.[2]

History and Physical

Clinical presentation depends on the severity of infection, patient comorbidities, and site of the aneurysm.[26] Risk factors that raise suspicion for an infected aneurysm are intravenous drug use, invasive procedures, immunocompromised state, or history of endocarditis.

The most common manifestations are fever, pulsatile mass, local pain, and inflammation in the arterial site (back pain in the aorta, headaches in intracranial vessels).[6] Due to the non-specific nature of these signs, many patients are evaluated as fever of unknown origin and remain undiagnosed until there are severe symptoms of sepsis, thrombosis, hemorrhage, or rupture.

Local expansion of the infection may result in psoas abscess formation (flank pain, limping and fever), vertebral osteomyelitis, dysphagia, and hoarseness due to the impingement of laryngeal nerve, and hemoptysis.[27][28][29]

Formation of the fistula may result in high output heart failure or expanding hematoma formation.[30][31][30]

Physical exam shows signs of local inflammation resulting in tender indurated mass and bruit on examination (50% of cases).[12] Cerebral aneurysms present as stroke or subarachnoid hemorrhage.

Evaluation

The presence of risk factors in history, in combination with clinical features, should prompt further evaluation for Mycotic aneurysms. There is no diagnostic algorithm or criteria to make the diagnosis, but a combination of clinical, laboratory, imaging, and intraoperative findings suggest the diagnosis of an infected aneurysm. Clinical presentation with fever, local findings, immunosuppressive state, presence of atherosclerosis risk factors, and concomitant infection. Laboratory findings are elevated inflammatory parameters CRP, ESR, leucocytosis, positive blood culture[3]. Intraoperative findings include 

Bacterial cultures are positive in 50-85% of the cases.[4]

Radiologic findings are the most sensitive and specific indicators. Findings that are highly suggestive include:[32][33][34][35]

  • Saccular with lobulated contours 
  • Soft tissue inflammation surrounding the vessel wall (seen as perivascular contrast enhancement)
  • Intramural air or air collection around the blood vessel
  • Perianeurysmal fluid collection

Contrast-enhanced CT scan is the initial imaging modality of choice for aortic aneurysms, contrast-enhanced MR angiography is a suitable alternative. Digital subtraction angiography can provide the same information, although it is more invasive.[26] Transthoracic echo is the preferred imaging modality for coronary aneurysms.[36] Nuclear scans have been largely used for the detection of graft infection.[37] Patients with infectious endocarditis may have multiple aneurysms, so they require more extensive angiography and imaging studies.

The monitoring of antibiotic therapy is done by serial inflammatory markers, and serial imaging studies are performed for patients before and after definitive surgery.

Treatment / Management

All patients require prolonged antibiotic therapy tailored to the culture and sensitivity results. A course of 6-8 weeks of medical therapy is recommended, but the duration is prolonged if there is evidence of persistent infection.[38] Response to therapy is monitored via serial white counts, inflammatory markers, and resolution of fever and hemodynamic stability. Empiric antibiotics are a combination of vancomycin with an agent with activity against gram-negative organisms, to cover for salmonellae, such as ceftriaxone, a fluoroquinolone, or piperacillin-tazobactam. Definitive management requires the removal of all infected tissue by surgical interventions. This includes debridement with or without revascularization via endovascular or open procedure consisting of ligation and resection or bypass with an extra-anatomic bypass or in-situ graft insertion. 

The procedure is chosen based on aneurysm location, the extent of the infection, the fitness of the patient, and the surgeon's preference.

In general, proximal ligation and resection of the aneurysm is a suitable approach for peripheral arteries and splanchnic vessels. Homografts involving segments of medium size vessels like an iliac artery or saphenous vein are suitable for renal, visceral, carotid or femoral arteries. Larger vessels like aorta with minimal purulence are managed with reconstruction with an in situ graft, and the conduit is covered with an omental pedicle to reduce the risk of persistent infection. There is no consensus on the ideal graft; options include rifampin soaked dacron graft, cryopreserved aortic graft, or femoral vein graft. Persistent purulence and systemic signs of inflammation or extensive aortic or paraaortic purulence suggest the need for an extra-anatomic bypass. Long term antimicrobial suppression therapy is considered if the emergency surgical procedure is performed for graft placement in the infected surgical site.   

Perioperative mortality is high (~20%) [39][3] for open surgery, and thus there is growing interest in endovascular therapies, which are a suitable alternative in patients with high perioperative risk or as a bridging procedure before definitive repair in patients who are in severe sepsis.[26][40] Some studies suggest high early mortality rates with open surgery vs. endovascular repair, but long term outcomes are comparable.[41][42] 

Infections occurring after endovascular or open repair should be treated with systemic antibiotics.[26]

Differential Diagnosis

Differential diagnoses for mycotic aneurysms can be various, which is attributable to the involvement of various organ systems. Following are some of the important differentials which need to be considered when suspecting the diagnosis of a mycotic aneurysm:

  • Cellulitis
  • Atherosclerotic aortic aneurysm (fusiform enlargement, with the presence of calcification and slow course in the absence of fever or systemic signs of infection)
  • Pyelonephritis: Renal artery mycotic aneurysm in transplanted kidneys
  • Inflammatory aortitis and aneurysm due to vasculitides
  • Intracranial mycotic aneurysms may present similar to meningitis, septic thrombophlebitis, or orbital cellulitis.

Toxicity and Side Effect Management

Long-term antimicrobial therapy for infection suppression may result in antibiotic-related side-effects i.e. tendinopathy with fluoroquinolones.

Prognosis

Survival depends on the location of the aneurysm. Infected aortic aneurysms have generally poor outcomes, untreated aneurysms of the aorta are almost universally fatal. Indicators of poor outcomes are female sex, a presentation with hemodynamic instability and shock or fever at the time of surgery, immunosuppressed state, extensive involvement of the aorta, and peri-aortic areas.[3] Endovascular repair has shown to have better survival in comparison with open surgical repair in experimental studies.[41][42][43]

Long-term outcomes are related to the type of procedure for treatment, but overall survival in patients who respond to medical therapy is good, and no long term disabilities are seen. Patients who have an inadequate clearance of infection, graft reinfections have a poor prognosis with nearly 100% mortality rate if graft remains in-situ.

Complications

Untreated aneurysms are at risk of rupture (~60%), sepsis, thrombosis, and distal ischemia or multiorgan failure.

Complications of in-situ surgical repair are related to the prolonged operating time and resultant distal ischemia, such as myocardial infarction, cerebrovascular accident, ischemic bowel, or acute kidney injury. Late complications of in-situ grafts are reinfection, graft failure, paraaortic leak, due to anastomotic failure or fistula formation. In-situ graft infections are associated with 100% mortality within two years if the graft remains in-situ.[26]

The extra-anatomic bypass has fewer intraoperative complications, but the majority of the patients eventually develop limb ischemia or severe claudication.[26]

Postoperative and Rehabilitation Care

Peri-operative mortality rates of open surgery approach 20% and postoperative complications (seen in 60%) are distal ischemia and amputation, renal failure, respiratory failure requiring prolonged mechanical ventilation, and multiorgan failure.[44][3]

Complications of extra-anatomic bypass procedures are aortic stump disruption, amputation, reinfection.[42]

Rehabilitation care: Many studies report prolonged hospitalization (median approximately 58 days) after surgery. Many patient require prolonged physical and occupational therapy and a gradual return to baseline activity.[45]

Consultations

Infectious disease consult service must be involved in the care in case of complicated or multi-drug resistant infections.

Deterrence and Patient Education

Patients are advised to remain in the hospital till the improvement of symptoms or resolution of fever and septic state. During the early post-operative phase, it is advisable to admit the patient in ICU. Patients should be educated about the risks and complications of the procedure and alternative options. Moreover, these patients require prolonged antibiotic therapy. Some authors suggest lifelong therapy, hence patient education is required. 

Instruction for post-operative care for patients are:

  • Wear loose clothing that does not irritate the wound
  • Do not soak in the bathtub, hot tub, or swimming pool soon after surgery
  • Clean incision with soap and water every day after wound epithelialization occurs
  • Change wound dressings frequently
  • Avoid any lotions, creams or herbal remedies on the wound
  • A gradual return to activity is advised

As most patients are in the older age group, physiotherapy and occupational therapy may be advised.

Since mycotic aneurysms are associated with atherosclerosis, aggressive risk factor modification is also advised in these patients (DASH diet, smoking cessation, statins, aspirin).

Enhancing Healthcare Team Outcomes

A mycotic aneurysm is a rare disease with a fulminant course. Although considered rare, the incidence has never been accurately studied, and data comes primarily from case series and summaries. There is evidence that incidence is increasing in the last two decades due to an increase in risk factors of atherosclerosis and immunosuppression.[46] Pathogenesis is complex with a combination of risk factors (atherosclerosis, arterial injury) and bacterial infection of the vessel wall. The diagnosis is challenging due to non-specific clinical features, manifestations similar to less benign differentials (spinal disease or urinary tract infection in an aortic aneurysm), and no clear diagnostic criteria. 

Management is demanding due to the kind of invasive surgical interventions involved and patient comorbidities that predispose to the infection. Medical therapy alone is associated with 50% mortality, and most experts recommend surgical intervention in combination with prolonged antimicrobial therapy. All vascular procedures are considered high risk for vulnerable patients and require a high degree of skills and care coordination among different team members. Most cases present to the hospitalist or general surgeon, but it is advisable to involve the vascular surgeon and infectious disease physician early to minimize any delay in intervention. Postoperative care relies heavily on nursing care, pharmacy, physical and occupational therapy.

The vast majority of mortality and morbidity with the aneurysm is associated with extensive infection by the time of diagnosis. Therefore, having a high index of suspicion and early diagnosis may improve patient outcomes. Lack of standardized definition and criteria for diagnosis and management also contributes to variability in outcomes in different studies, and a consensus statement from professional societies may alleviate this concern.


References

[1] Osler W, The Gulstonian Lectures, on Malignant Endocarditis. British medical journal. 1885 Mar 14;     [PubMed PMID: 20751196]
[2] Stone JR,Bruneval P,Angelini A,Bartoloni G,Basso C,Batoroeva L,Buja LM,Butany J,d'Amati G,Fallon JT,Gittenberger-de Groot AC,Gouveia RH,Halushka MK,Kelly KL,Kholova I,Leone O,Litovsky SH,Maleszewski JJ,Miller DV,Mitchell RN,Preston SD,Pucci A,Radio SJ,Rodriguez ER,Sheppard MN,Suvarna SK,Tan CD,Thiene G,van der Wal AC,Veinot JP, Consensus statement on surgical pathology of the aorta from the Society for Cardiovascular Pathology and the Association for European Cardiovascular Pathology: I. Inflammatory diseases. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology. 2015 Sep-Oct;     [PubMed PMID: 26051917]
[3] Oderich GS,Panneton JM,Bower TC,Cherry KJ Jr,Rowland CM,Noel AA,Hallett JW Jr,Gloviczki P, Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results. Journal of vascular surgery. 2001 Nov;     [PubMed PMID: 11700493]
[4] Brown SL,Busuttil RW,Baker JD,Machleder HI,Moore WS,Barker WF, Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms. Journal of vascular surgery. 1984 Jul;     [PubMed PMID: 6436514]
[5] Baddour LM,Wilson WR,Bayer AS,Fowler VG Jr,Tleyjeh IM,Rybak MJ,Barsic B,Lockhart PB,Gewitz MH,Levison ME,Bolger AF,Steckelberg JM,Baltimore RS,Fink AM,O'Gara P,Taubert KA, Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015 Oct 13;     [PubMed PMID: 26373316]
[6] Huang YK,Chen CL,Lu MS,Tsai FC,Lin PL,Wu CH,Chiu CH, Clinical, microbiologic, and outcome analysis of mycotic aortic aneurysm: the role of endovascular repair. Surgical infections. 2014 Jun;     [PubMed PMID: 24800865]
[7] Maeda H,Umezawa H,Goshima M,Hattori T,Nakamura T,Umeda T,Shiono M, Primary infected abdominal aortic aneurysm: surgical procedures, early mortality rates, and a survey of the prevalence of infectious organisms over a 30-year period. Surgery today. 2011 Mar;     [PubMed PMID: 21365414]
[8] Reddy DJ,Shepard AD,Evans JR,Wright DJ,Smith RF,Ernst CB, Management of infected aortoiliac aneurysms. Archives of surgery (Chicago, Ill. : 1960). 1991 Jul;     [PubMed PMID: 1854247]
[9] Ben Messaoud M,Bouchahda N,Mahjoub M,Hmida B,Dridi Z,Gamra H, Case Report: Coronary artery stent infection with mycotic aneurysm secondary to tricuspid valve infective endocarditis. F1000Research. 2019;     [PubMed PMID: 31656587]
[10] McCready RA,Bryant MA,Divelbiss JL,Chess BA,Chitwood RW,Paget DS, Arterial infections in the new millenium: an old problem revisited. Annals of vascular surgery. 2006 Sep;     [PubMed PMID: 17039259]
[11] De Caridi G,Massara M,Spinelli F,Grande R,Butrico L,Rende P,Amato M,Compagna R,Amato B,de Franciscis S,Serra R, An uncommon case of arterial aneurysms association with high plasma levels of Matrix Metalloproteinase-9 and Neutrophil Gelatinase-Associated Lipocalin. Open medicine (Warsaw, Poland). 2015;     [PubMed PMID: 28352742]
[12] Johnson JR,Ledgerwood AM,Lucas CE, Mycotic aneurysm. New concepts in therapy. Archives of surgery (Chicago, Ill. : 1960). 1983 May;     [PubMed PMID: 6687676]
[13] Patel S,Sharma AK,Meena D,Garg PK,Tiwari S,Ghosh TS, Extracranial carotid artery pseudoaneurysm due to {i}Mycobacterium tuberculosis{/i}. Asian cardiovascular     [PubMed PMID: 32483974]
[14] Moh DR,Badjé A,Ello NF,N'takpé JB,Anzouan-Kacou JB,Kouamé GM,Ackoundzé S,Boccara F,Ba-Gomis O,Eholié SP,Anglaret X,Danel C, [Aortic aneurism dissection in an adult patient with tuberculosis infected with HIV-1 during immune reconstitution inflammatory syndrome]. The Pan African medical journal. 2018;     [PubMed PMID: 30918538]
[15] Dick J,Tiwari A,Menon J,Hamilton G, Abdominal aortic aneurysm secondary to infection with Pseudomonas aeruginosa: a rare cause of mycotic aneurysm. Annals of vascular surgery. 2010 Jul;     [PubMed PMID: 20409680]
[16] Haroon Y,Bhalla A,El-Tahir A, Listeria monocytogenes: a rare cause for an infected abdominal aortic aneurysm. Vascular and endovascular surgery. 2011 Nov;     [PubMed PMID: 21937471]
[17] Chen YJ,Chen SY,Wang JT,Hsueh PR, Mycotic aneurysm caused by gas-forming serotype K5 Klebsiella pneumoniae. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 2009 Mar;     [PubMed PMID: 18774741]
[18] Ballaith A,Raffort J,Rajhi K,Salucki B,Drai C,Jean-Baptiste E,Hassen-Khodja R,Lareyre F, Mycotic aortic and left iliac ruptured aneurysm due to {i}Escherichia Coli{/i}: a case report and literature overview. Acta chirurgica Belgica. 2020 Apr 21;     [PubMed PMID: 32253984]
[19] Kozaki S,Miyamoto S,Uchida K,Shuto T,Tanaka H,Wada T,Anai H, Infected thoracic aortic aneurysm caused by {i}Clostridium ramosum{/i}: A case report. Journal of cardiology cases. 2019 Sep;     [PubMed PMID: 31497176]
[20] Bucknell SJ,Le T,Amerena J,Hill DG,McDonald M, Aortic dissection associated with Campylobacter aortitis. Heart, lung     [PubMed PMID: 16352001]
[21] Nath AF,Clarke MJ, Multiple mycotic aneurysms infected with Haemophilus influenzae. Annals of vascular surgery. 2014 Apr;     [PubMed PMID: 24495332]
[22] Loïez C,Carnoy C,Decoene C,Pradel E,Fichel C,Courcol R,Wallet F, First case of postaneurysmal prosthetic vascular infection due to a nonsuperantigenic Yersinia pseudotuberculosis strain. Journal of clinical microbiology. 2010 Aug;     [PubMed PMID: 20573875]
[23] Kim MG,Jeon JW,Ryu IH,Lee JJ,Kim JS,Choi JW,Cho BS,Yoon HJ, Mycotic abdominal aortic aneurysm caused by bacteroides thetaiotaomicron and acinetobacter lwoffii: the first case in Korea. Infection     [PubMed PMID: 24693472]
[24] Wu SJ,Huddin JC,Wanger A,Estrera AL,Buja LM, A case of Brucella aortitis associated with development of thoracic aortic aneurysm and aortobronchial fistula. Cardiovascular pathology : the official journal of the Society for Cardiovascular Pathology. 2019 Mar - Apr;     [PubMed PMID: 30513449]
[25] Miller DV,Oderich GS,Aubry MC,Panneton JM,Edwards WD, Surgical pathology of infected aneurysms of the descending thoracic and abdominal aorta: clinicopathologic correlations in 29 cases (1976 to 1999). Human pathology. 2004 Sep;     [PubMed PMID: 15343514]
[26] Stenson KM,Grima MJ,Loftus IM,Tripathi RK, Recommendations for management of infected aortic pathology based on current evidence. Seminars in vascular surgery. 2019 Mar - Jun;     [PubMed PMID: 31540659]
[27] Yamamoto H,Yamamoto F,Izumoto H,Tanaka F,Ishibashi K, Repetitive contained rupture of an infected abdominal aortic aneurysm with concomitant vertebral erosion. Annals of vascular surgery. 2010 Aug;     [PubMed PMID: 20471795]
[28] Masumoto H,Shimamoto M,Yamazaki F,Nakai M,Fujita S,Miura Y, Airway stenosis associated with a mycotic pseudoaneurysm of the common carotid artery. General thoracic and cardiovascular surgery. 2008 May;     [PubMed PMID: 18470692]
[29] Piracha S,Mahmood A,Qayyum N,Ganaie MB, Massive haemoptysis secondary to mycotic pulmonary artery aneurysm in subacute invasive aspergillosis. BMJ case reports. 2018 Apr 19;     [PubMed PMID: 29674397]
[30] Liu CH,Fu CK, An Unusual Cause of Gastrointestinal Bleeding-Mycotic Aneurysm with Aortoduodenal Fistula. The American journal of the medical sciences. 2020 May;     [PubMed PMID: 32171467]
[31] Shiraishi M,Ohki S,Misawa Y, Mycotic superior mesenteric pseudoaneurysm draining into a vein. Interactive cardiovascular and thoracic surgery. 2011 Jan;     [PubMed PMID: 21098424]
[32] Vogelzang RL,Sohaey R, Infected aortic aneurysms: CT appearance. Journal of computer assisted tomography. 1988 Jan-Feb;     [PubMed PMID: 3335648]
[33] Azizi L,Henon A,Belkacem A,Monnier-Cholley L,Tubiana JM,Arrivé L, Infected aortic aneurysms: CT features. Abdominal imaging. 2004 Nov-Dec;     [PubMed PMID: 15185036]
[34] Gonda RL Jr,Gutierrez OH,Azodo MV, Mycotic aneurysms of the aorta: radiologic features. Radiology. 1988 Aug;     [PubMed PMID: 3260676]
[35] Blair RH,Resnik MD,Polga JP, CT appearance of mycotic abdominal aortic aneurysms. Journal of computer assisted tomography. 1989 Jan-Feb;     [PubMed PMID: 2910923]
[36] Buono A,Maloberti A,Bossi IM,Piccaluga E,Piccalò G,Oreglia JA,Moreo A,Russo CF,Oliva F,Giannattasio C, Mycotic coronary aneurysms. Journal of cardiovascular medicine (Hagerstown, Md.). 2019 Jan;     [PubMed PMID: 30418268]
[37] Puges M,Bérard X,Ruiz JB,Debordeaux F,Desclaux A,Stecken L,Pereyre S,Hocquelet A,Bordenave L,Pinaquy JB,Cazanave C, Retrospective Study Comparing WBC scan and {sup}18{/sup}F-FDG PET/CT in Patients with Suspected Prosthetic Vascular Graft Infection. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2019 Jun;     [PubMed PMID: 31130421]
[38] Hollier LH,Money SR,Creely B,Bower TC,Kazmier FJ, Direct replacement of mycotic thoracoabdominal aneurysms. Journal of vascular surgery. 1993 Sep;     [PubMed PMID: 8377242]
[39] Kim HH,Kim DJ,Joo HC, Outcomes of Open Repair of Mycotic Aortic Aneurysms with {i}In Situ{/i} Replacement. The Korean journal of thoracic and cardiovascular surgery. 2017 Dec;     [PubMed PMID: 29234609]
[40] Sörelius K,Wanhainen A,Wahlgren CM,Langenskiöld M,Roos H,Resch T,Vaccarino R,Arvidsson B,Gillgren P,Bilos L,Pirouzram A,Holsti M,Mani K, Nationwide Study on Treatment of Mycotic Thoracic Aortic Aneurysms. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2019 Feb;     [PubMed PMID: 30340857]
[41] Marchetti A A,Fm O,F V,Dàvila B O,A I, The safety of EVAS surgical conversion in a comparative monocentric analysis. Annals of vascular surgery. 2020 May 18;     [PubMed PMID: 32439532]
[42] Lin SY,Liu KS,Chu SY,Chen CM,Yu SY,Su IH,Ko PJ,Su TW, Response Findings after Treatment and Outcomes on CT after Endovascular Repair of Mycotic Aortic Aneurysm. Journal of vascular and interventional radiology : JVIR. 2020 Jun;     [PubMed PMID: 32414571]
[43] Luo CM,Chan CY,Chen YS,Wang SS,Chi NH,Wu IH, Long-term Outcome of Endovascular Treatment for Mycotic Aortic Aneurysm. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2017 Oct;     [PubMed PMID: 28826996]
[44] Kyriakides C,Kan Y,Kerle M,Cheshire NJ,Mansfield AO,Wolfe JH, 11-year experience with anatomical and extra-anatomical repair of mycotic aortic aneurysms. European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery. 2004 Jun;     [PubMed PMID: 15121107]
[45] Nemoto Y,Hosoi Y,Hoshina K,Nunokawa M,Kubota H,Watanabe T, In Situ Reconstruction with Extended Debridement in Patients with Mycotic Abdominal Aortic Aneurysms. Annals of vascular diseases. 2017 Jun 25;     [PubMed PMID: 29034046]
[46] Mughini-Gras L,Pijnacker R,Duijster J,Heck M,Wit B,Veldman K,Franz E, Changing epidemiology of invasive non-typhoid Salmonella infection: a nationwide population-based registry study. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. 2019 Nov 21;     [PubMed PMID: 31760114]